JAVA 2019¿ La enfermedad vascular periférica es una enfermedad benigna?. Impacto en

mortalidad, morbilidad y gasto.

Médico Staff. Departamento de Cardiología

Intervencionista

- Fundación Favaloro -

- Buenos Aires - Argentina -

Dr. León Valdivieso.

Conflicto de interés:

MEDTRONIC:

Proctor en intervenciones Periféricas

PAD benign?

Feringa et al. Arch Intern Med. 2007;167(22):2482-2489

PAD benign?

Lower extremity peripheral arterial disease (PAD) is a manifestation

of systemic atherosclerosis and is associated with increased

cardiovascular morbidity and mortality.

The prevalence of PAD has been reported to range from 4% in

patients 40 years and older to over 20% in patients 70 years and

older.

It has been estimated that approximately 8 to 12 million people in

the United States have this disease. However, prevalence values may

be even higher since a substantial proportion of the population has

undetected PAD

Baubeta Fridh et al. European Journal of Vascular and Endovascular Surgery. 54. 10.1016/j.ejvs.2017.07.005

PAD benign?

16,889 patients with PAD (IC, n = 6272; CLI, n = 10,617). F-U 6 y.

Amputation Rates, Mortality, and Pre-operative Comorbidities in

Patients Revascularised for Intermittent Claudication or Critical Limb

Ischaemia:

A Population Based Study.

Amputation in IC was 0.4% per year (0.3 – 0.5)

Amputation in CLI was 12% (11.3 – 12.6) the 6 m following

revascularization and thereafter 2% per year.

The cumulative incidence of death or amputation 3 y after

revascularization was 12.9% (12 – 13.9) in IC and 48.8% (47.7 -49.8)

in CLI.

Swaminathan et al. Vascular Health and Risk Management 2014:10 417–424

Lower extremity amputation in peripheral artery disease: improving

patient outcomes

Klaphake et al. Clin Interven Aging 2017;12:1985-1992

Mortality after major amputation in elderly patients with critical

limb ischemia.

651 patients ≥ 70 y with CLI. 168 major amputations

Overall Mortality after major amputation

Golomb et al. Circulation. 2006;114:688-699

PAD benign?

Coronary Artery Disease (CAD) in patients with PAD (Global 14 – 90%)

Clinical History plus ECG 19-47%

Stress Tests (PEG, Ta-dipiridamole) 62-63%

Angiography 90%

Cerebro-Vascular Disease (CVD) in patients with PAD

Duplex > 30% 51-72%

Duplex > 70% 25%

Clinical Disease 0-35%

Peripheral Arterial Disease

Morbidity and Mortality Implications

Golomb et al. Circulation. 2006;114:688-699

PAD benign?

Coronary and Cerebral Vascular Disease (CCVD) in patients with PAD

with PAD without PAD

Men 29% 12%

Women 21% 9%

PAD in patientes with CCVD

with CCVD without CCVD

Men 32% 13%

Women 25% 12%

Peripheral Arterial Disease

Morbidity and Mortality Implications

Golomb et al. Circulation. 2006;114:688-699

PAD benign?

CCVD Mortality in patients with PAD

2 – 6 times higher than patients without PAD

10 y Overall Mortality in patientes with PAD

Normal Subjets 15%

Asymptomatic PAD 45%

Severe Symptomatic PAD 75%

Peripheral Arterial Disease

Morbidity and Mortality Implications

Feringa et al. Arch Intern Med. 2007;167(22):2482-2489

A Prognostic Risk Index for Long-term Mortality in Patients With Peripheral Arterial

Disease2642 ptes with an ABI ≤ 0.90 were randomly divided into derivation (n=1332) and validation (n=1310) cohorts

Feringa et al. Arch Intern Med. 2007;167(22):2482-2489

A Prognostic Risk Index for Long-term Mortality in Patients With

Peripheral Arterial Disease

Mueller et al. J Vasc Surg 2014;59:1291-9

PAD benign?

Mortality rates and mortality predictors in patients with symptomatic

peripheral artery disease stratified according to age and diabetes

487 patients with symptomatic PAD

10 vs 5%

PAD vs Control

23 vs 7%

38 vs 22%

52%

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10

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40

50

60

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80

90

100

1 2 3 4 5 6 7 8 9 10

Sobrevida libre de

amputación

Sobrevida

Sobrevida libre de

reintervención

Sobrevida libre de

eventos

PAD benign?

Curvas de sobrevida actuarial de pacientes con ATP

infrapatelar debida a CLI en FF

Feringa et al. Arch Intern Med. 2007;167(22):2482-2489

PAD benign?

COSTOS

Es difícil hacer un análisis de costos real de los pacientes con PAD

ya que existen amplias variaciones entre los distintos paises.

Los pacientes con CLI son más añosos, más frecuentemente

diabéticos, HTA, IRC, con enfermedad coronaria y carotídea.

Suelen tener más reintervenciones y reinternaciones.

Varias series coinciden en que los costos son mayores en aquellos

pacientes que terminan en amputaciones mayores que en quienes

son revascularizados con éxito.

PAD benign? CONCLUSIONES

La presencia de enfermedad vascular periférica NO es una condición

benigna. Es una grado muy avanzado de enfermedad aterosclerótica de

múltiples territorios con muchos órganos afectados o en riesgo.

A mayor severidad mayor grado de malignidad.

Se asocia a significativos aumentos de amputaciones, incapacidad,

enfermedad coronaria y carotídea, y a mayor tasa de mortalidad de

causa cardiovascular (x6) y global (x3).

Los costos parecerían ser significativamente altos.

Dado que las amputaciones se asocian a más costos y peores

resultados, deberían extremarse esfuerzos para llevar a cabo

revascularizaciones tempranas y exitosas que eviten las mismas.

Gracias por su atención